Posted tagged ‘home birth’

The safest place to have a baby is in a hospital

February 10, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Two big studies have been published in the last few weeks, both of which have confirmed previous data: home birth is not as safe as hospital birth. These studies show that having a baby at home increases the risk of your baby dying by about 4 times. That really is a big increased risk—especially considering that most home births are supposedly low-risk pregnancies. Those babies should be less likely to die.

From the January, 2014 issue of the American Journal of Obstetrics and Gynecology comes a study of over 10 million babies born in 2007-2009. This study looked only at term deliveries, excluding small babies and twins and babies with congenital anomalies (that’s now the preferred term. We don’t really say “birth defects” any more.) The babies were then divided into groups by the setting of their delivery: in a hospital, in a free-standing birth center, or at home. The results are stark. The neonatal mortality among babies delivered by a midwife in a hospital was 3.1 per 10,000 births. For midwives delivering at home, the death rate was 13.2 per 10,000 (about four times the hospital risk.) There were far more babies born in the hospital than at home, but plenty of home births were analyzed, including over 48,000 by midwives. This was a large study with a reliable data set cross referenced from CDC data, and if anything it underestimates home birth mortality because babies transferred to the hospital because of complications during home birth counted as hospital babies.

The second January, 2014 study came out in the Journal of Midwifery and Women’s Health. This study did not have a built-in comparison group—it collected data only from women intending to have a home delivery by midwife from 2004 to 2009. The authors looked at many outcomes, including whether the babies successfully delivered at home, Apgar scores, and their use of medical interventions. The overall intrapartum death rate was 13 out of 10,000—and that includes only deaths during labor itself (not including babies who died shortly after birth.) Note that the death rate, 13 out of 10,000, just about matches the death rate for home midwife births from the ACOG study, which was 13.2 per 10,000. Though this study had no built-in comparison group, the rate is much higher than the hospital death rate from the ACOG study. And, again, the four-fold increased death rate is very likely an underestimate—this number does not include babies who barely survived delivery and died shortly afterwards. Also, data submission was entirely voluntary, capturing only 20-30% of home births. I’m thinking that midwives who delivered dead babies may have been somewhat less motivated to submit their data.

Though the total number of deaths was not large—the vast majority of deliveries in either setting were successful—a four-fold or more increase in death risk is not something I think most families would consider acceptable. The fact of the matter is that obstetric complications are not always predictable, and that hospitals are the place where medical interventions can be done quickly. These studies concerned deaths, but keep in mind that for every dead baby, there are many more that suffer brain damage with lasting handicaps.

Based on these and other good, large studies, a hospital birth dramatically improves the safety of delivery compared to having a baby at home. Further studies could improve the safety of home births—by developing stricter criteria to limit home births to the lowest risk pregnancies, and by making sure that home birth midwives are qualified to handle complications. But even in an optimal home birth situation, with a very competent midwife, some mothers and babies will suffer complications like massive bleeding or strokes or placental separations or umbilical cord catastrophies that will require near-instant hospital assistance to help mom and baby survive. Sometimes, there just isn’t time to wait for an ambulance. If you want the safest choice for your delivery, choose a hospital. And then bring your healthy baby home.

Home birth: Is there added risk?

August 15, 2010

The Pediatric Insider

© 2010 Roy Benaroch, MD

Thinking of having your baby’s delivery at home? You might want to think again.

Each year in the United States about 25,000 babies are delivered at home; 75% of these are planned, low-risk births (presumably the rest are panicked moments that make good stories later.) Researchers recently published a study pooling data from multiple worldwide reports comparing health outcomes of 342,056 planned home deliveries versus 207,511 hospital births in industrialized, western countries.

The good news for proponents of home delivery: overall the women giving birth had fewer episiotomies, fewer c-sections, and less-invasive obstetric monitoring. They were also less likelye to develop post-partum infections and hemorrhage.

However, there is a price: the neonatal mortality overall was doubled among babies born at home. In fact, three times as many died if you exclude babies with known congenital defects (many of whom would not be resuscitated whether at home or in the hospital.) The overall death rate at home was 0.2%, versus 0.09% in the hospital, even though home babies were certainly far less “high risk” to begin with.

The data wasn’t collected in a way that allowed the authors to more-specifically identify risk factors for poor neonatal outcome. There are several, well-established “high risk” criteria that already preclude home birth: prematurity, maternal health risks, obesity, prior c-section, or not having a hospital nearby for transport in case of emergencies. There may be other risk factors that are less well known. But I’m sure that at least some of these babies who died had no risk factors at all.

National organizations representing nurse-midwives have criticized the study and its conclusion, claiming that they used too much older data and too many studies that poorly differentiated planned from unplanned home births. However, the sheer size of this study dwarfs all previous reports, and I think it is difficult to imaging that such a big difference is only the result of how and when the data was collected.

The vast majority of planned, low-risk home births will be successful, and chances are you’ll get yourself a happy and healthy baby whether the birth is at home or in a hospital. But the chances are better in a hospital, where if things go wrong high-tech intervention to help a mother or baby is available. Not all emergencies can be planned or expected. Staying home is a chance you might not want to take.